• The covered procedures are listed by American Dental Association Common Dental Terminology (CDT) code so you’ll always know what services are included in your plan. Remember, if a procedure is not listed on the Patient Charge Schedule, then it’s not a covered benefit on your plan. • The coinsurance is listed as a percentage of the total cost that you owe directly to the dentist and is calculated based on the network dentist’s contracted fee schedule, which is the amount Cigna agrees to pay dentists for their services. The contracted fee schedules vary by network dentist. Your exact out-of-pocket costs are calculated by multiplying the coinsurance percentage for a given procedure by the dentist’s contracted fee for that same procedure. If you’d like more information about your specific out-of-pocket costs, call us 24/7 at 1.800.Cigna24 or the phone number on your ID card. • The copay is the fixed dollar amount that you owe directly to the dentist. Your out-of-pocket cost for any covered procedure with a copay is only that exact dollar amount. • This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist, unless otherwise authorized by Cigna Dental as described in your plan documents. • This Patient Charge Schedule applies to Specialty Care when an appropriate referral is made to a Network Specialty Periodontist or Oral Surgeon.You must verify with the Network Specialty Dentist that your treatment plan has been authorized for payment by Cigna Dental. Prior authorization is not required for specialty referrals for Pediatric, Orthodontic, and Endodontic services. You may select a Network Pediatric Dentist for your child under the age of 7 by calling Member Services at 1.800.Cigna24 to get a list of Network Pediatric Dentists in your area. Coverage for treatment by a Pediatric Dentist ends on your child’s 7th birthday; however, exceptions for medical reasons may be considered on an individual basis.Your Network General Dentist will provide care upon your child’s 7th birthday. Q2-00 CIGNA DENTAL CARE® (*DHMO) PATIENT CHARGE SCHEDULE This Patient Charge Schedule describes the benefits of your dental plan and includes a list of covered procedures, and coinsurance percentage or copay for each covered procedure. Important Highlights Subject to regulatory approval 92260 856585 02/13 Q2-00
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• The covered procedures are listed by American Dental Association Common Dental Terminology (CDT) code so you’ll always know what services are included in your plan.Remember,ifaprocedureisnotlistedonthePatientChargeSchedule,thenit’snotacoveredbenefitonyourplan.
• The coinsurance is listed as a percentage of the total cost that you owe directly to the dentistandiscalculatedbasedonthenetworkdentist’scontractedfeeschedule,whichistheamountCignaagreestopaydentistsfortheirservices.Thecontractedfeeschedulesvarybynetworkdentist.Yourexactout-of-pocketcostsarecalculatedbymultiplyingthecoinsurancepercentageforagivenprocedurebythedentist’scontractedfeeforthatsameprocedure.Ifyou’dlikemoreinformationaboutyourspecificout-of-pocketcosts,callus24/7at1.800.Cigna24orthephonenumberonyourIDcard.
• The copay is the fixed dollar amount that you owe directly to the dentist.Yourout-of-pocketcostforanycoveredprocedurewithacopayisonlythatexactdollaramount.
Diagnostic/preventive – Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month period: Periodic oral evaluations (D0120), comprehensive oral evaluations (D0150), comprehensive periodontal evaluations (D0180), and oral evaluations for patients under 3 years of age (D0145).
D0160 Detailedandextensiveoralevaluation–problemfocused,byreport(limit 2 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation)
D0330 X-rays(panoramicradiographicimage)–(limit 1 every 3 years)
0%
D0368 ConebeamCTcaptureandinterpretationforTMJseriesincludingtwoormoreexposures(limit 1 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation)
D1206 Topicalapplicationoffluoridevarnish(limit 2 per calendar year). There is a combined limit of a total of 2 D1206s and/or D1208s per calendar year.
Crown and bridge – All charges for crown and bridge (fixed partial denture) are per unit (each replacement or supporting tooth equals 1 unit). Coverage for replacement of crowns and bridges is limited to 1 every 5 years.
Complexrehabilitation–Anadditional$125chargeperunitformultiplecrownunits/complexrehabilitation (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines)
Periodontics (treatment of supporting tissues [gum and bone] of the teeth) periodontal regenerative procedures are limited to 1 regenerative procedure per site (or per tooth, if applicable), when covered on the patient charge schedule. The relevant procedure codes are D4263, D4264, D4266 and D4267. Localized delivery of antimicrobial agents is limited to 8 teeth (or 8 sites, if applicable) per 12 consecutive months, when covered on the patient charge schedule.
Prosthetics (removable tooth replacement – dentures) includes up to 4 adjustments within first 6 months after insertion – Replacement limit 1 every 5 years.
Implant/abutment supported prosthetics – All charges for crown and bridge (fixed partial denture) are per unit (each replacement on a supporting implant(s) equals 1 unit). Coverage for replacement of crowns and bridges and implant supported dentures is limited to 1 every 5 years.
Complexrehabilitationonimplant/abutmentsupportedprostheticprocedures–Anadditional$125chargeperunitformultiplecrownunits/complexrehabilitation(6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for theguidelines)
Orthodontics (tooth movement) Orthodontic treatment (maximum benefit of 24 months of interceptive and/or comprehensive treatment. Atypical cases or cases beyond 24 months require an additional payment by the patient.)
General anesthesia/IV sedation – General anesthesia is covered when performed by an oral surgeon when medically necessary for covered procedures listed on the patient charge schedule. IV sedation is covered when performed by a periodontist or oral surgeon when medically necessary for covered procedures listed on the patient charge schedule. Plan limitation for this benefit is 1 hour per appointment. There is no coverage for general anesthesia or intravenous sedation when used for the purpose of anxiety control or patient management.
After your enrollment is effective:CallthedentalofficeidentifiedinyourWelcomeKit.Ifyouwishtochangedentaloffices,atransfercanbearrangedatnochargebycallingCignaDentalatthetollfreenumberlistedonyourIDcardorplanmaterials.Multiplewaystolocatea*DHMONetworkGeneralDentist:
* The term “DHMO” is used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care plans, and plans with open access features.
“Cigna,” “Cigna Dental Care” and “GO YOU” are registered service marks, and the “Tree of Life” logo is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (“CGLIC”), Cigna Health and Life Insurance Company (“CHLIC”), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. (“CDHI”) and its subsidiaries. The Cigna Dental Care plan is provided by Cigna Dental Health Plan of Arizona, Inc.; Cigna Dental Health of California, Inc.; Cigna Dental Health of Colorado, Inc.; Cigna Dental Health of Delaware, Inc.; Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes; Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska); Cigna Dental Health of Kentucky, Inc.; Cigna Dental Health of Maryland, Inc.; Cigna Dental Health of Missouri, Inc.; Cigna Dental Health of New Jersey, Inc.; Cigna Dental Health of North Carolina, Inc.; Cigna Dental Health of Ohio, Inc.; Cigna Dental Health of Pennsylvania, Inc.; Cigna Dental Health of Texas, Inc.; and Cigna Dental Health of Virginia, Inc. In other states, the Cigna Dental Care plan is underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc., and administered by CDHI.